Transcript Why Too Much Medicine is Making Us

BHCAG Summit
Minneapolis, MN
February 23, 2012
Shannon Brownlee, MS
Instructor, The Dartmouth Institute
Acting Director, New America Foundation Health Policy
Clinicians, patients and preferencesensitive (elective) care
•What do patients know about tradeoffs?
•What do they need to know?
•What do clinicians know about patient
preferences?
•How does knowledge change behavior?
Al Mulley
Michael Barry
Jack Fowler
Jack Wennberg
• Involves tradeoffs -- more than one
treatment exists; not getting treated is
often an option; and the outcomes are
different
• Decisions should be based on the
patient’s preferences . . .
• But provider opinion/preference often
determines which treatment is
delivered
PCI per 1,000 Enrollees (2003 – 2007)
 “Yes, medical therapy is as effective as
PCI, but when I see a lesion, the bottom
line is that the oculostenotic reflex always
wins out.”
 “[The patient] is not going to get out of
the cath lab without a stent.”
Grace A. Lin, et al ARCH INTERN MED/VOL 167 (NO. 15), AUG 13/27, 2007
WHAT DO PATIENTS KNOW
(1990s)?
 75% believed PCI would help prevent an MI
 71% believed PCI would help them live longer
 Less than half could name even one possible
complication of PCI
 85% were “consented” just before the procedure (by a
fellow or an NP)
From a survey of consecutive patients scheduled for an elective
coronary revascularization procedure at Yale New Haven
Hospital in 1997-1998. (Holmboe ES. JGIM 2000; 15:632)
What patients know (2010) . .
.
 88% believed PCI would help prevent an MI
 76% believed PCI would help them live longer
(Baystate Medical Center in 2007-2008
Rothberg MB. Annals Intern Med 2010; 153:307)
• Only 31% had activity
limiting chest pain
• Cardiologists’ perception of
the patient’s angina was often
greater than the patient’s
MB Rothberg Ann Intern Med. 2010 Sep 7;153(5):307-1
Well Bob, it looks like a paper cut, but just to be
sure, I like to do lots of catheterizations.
Relationship Between Procedure Indications and
Outcomes of Percutaneous Coronary Interventions by
American College of Cardiology/American Heart
Association Task Force Guidelines
H. Vernon Anderson et al Circulation 2005;112;2786-2791
CABG in
Minnesota
What do clinicians know about
what their patients prefer?
U. Mich Decision Survey
What do Clinicians Know?
Sepucha K, et al. Patient Education and Counseling 2008 and Lee et
al. 30th Annual Society for Medical Decision Making Conference,
Philadelphia, 2008.
DECISION Survey: How can you know if
you don’t ask?
Surgery:
 About 1/2 the time for the orthopedic surgeries;
1/3 for cataracts
 Screening:
 Less than 1/5 of the time for decisions about cancer
screening
 Medications:
 About 1/3 of the time
SOURCE: U. of Mich. DECISION Survey
What do patients know?
 Clinical experts identified 4-5
facts, e.g. common side effects
 Respondents were asked the
knowledge questions related to
their decision.
 For 8 out of the 10 decisions, less
than half of respondents could
get more than 1 of the knowledge
questions right.
U. Mich Decision Survey
Clinicians, patients and preferencesensitive care
•What do patients know about tradeoffs? Not
much
•What do they need to know? A lot more
•What do clinicians know about patient
preferences? Not much
•How does knowledge change behavior?
Behavior Changes
with Knowledge
GREATER
KNOWLEDGE
LEADS TO
Behavior
DIFFERENT CHOICES
* P < .01
Source: N. Cochran, MD, WRJ V.A.